Saturday, September 12, 2009

Twice as many adults could get the swine fluvaccine as scientists initially expected because the inoculation works in just one dose instead of two, federal officials announced Friday.

The preliminary data from American clinical trials of a vaccine come as a surprise and a relief to public health experts who feared there would not be enough vaccine to reach everyone who would need it.

The data confirm results from an Australian study released Thursday that also found that one dose is effective.

"This is very good news for the vaccination program, both with regard to the supply of the vaccine and its potential efficacy," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health. The agency is funding the American trials of two vaccines, one from drugmaker Sanofi Pasteur and another from CSL Ltd.

In the Sanofi vaccine tests, NIH scientists found that 96 percent of healthy adults ages 18 to 64 developed an immune response just eight days after receiving one 15-microgram shot. The percentage was lower in the elderly - 56 percent in people 65 and older. The CSL vaccine yielded similar results - 80 percent of adults 18 to 64 developed an immune response with one 15-microgram dose, while 60 percent of adults 65 and older did.

Fauci said researchers were not surprised that the elderly developed less of an immune response - the figures were similar to the response found when the elderly are given the seasonal flu shot. "Of course, we want to study that - can we ever make that better?" he said. "But it's right now right in the ballpark of what is the immune response in elderly individuals."

The data come from studies being conducted at the University of Maryland's Center for Vaccine Development and a handful of other academic centers nationwide that began testing the experimental vaccine on adults and children last month in a race to launch a mass vaccination campaign expected to start in mid-October.

Developing a safe and effective vaccine is crucial in the government's fight against the pandemic, which began with outbreaks in Mexico this spring and has killed 593 people nationwide - 3,205 around the globe - according to estimates by the federal Centers for Disease Control and Prevention and the World Health Organization.

Infectious disease experts have warned of an onslaught of the virus this fall and are bracing for the possibility that it could mutate and become deadlier.

Federal officials would not offer specifics about how the newest findings could alter the logistics of a vaccination campaign. The government has spent more than $1 billion for about 190 million doses of the vaccine from five manufacturers. Roughly 40 million doses are expected to be ready by the middle of next month and would be released as they become available.

The preliminary results of the Australian study, published in the New England Journal of Medicine, were similar to the American trials. Australian researchers found that 97 percent of the 240 adults who got one 15-microgram dose developed antibodies to the virus after just 10 days.

The trials were done by vaccine maker CSL, which is licensed to provide millions of doses of the vaccine in the United States.

Using less vaccine means not only being able to stretch supply farther, but it also means cutting down on costs and the frustrating logistics of lining people up for two shots, said Dr. Wilbur Chen, a vaccinologist who is helping to oversee the H1N1 vaccine trials at the University of Maryland's Center for Vaccine Development.

"I was elated when I found out the results," he said. "That was one of the best-case scenarios, seeing this vaccine working in people this well. We can rest much better at night, knowing that we will have more doses and we'll have an easier time to vaccinate the population. It was a headache, honestly, thinking about vaccinating people twice in 21 days. It's hard enough to get people to come back."

The initial trial results leave many unanswered questions. Scientists don't yet know whether one dose will be effective in children or pregnant women - the vaccine is still being tested in the groups. Results in children aren't expected for another two weeks and findings in pregnant women may not come until late October, Fauci said.

It's also unclear whether people with compromised immune systems would benefit from one dose rather than two. That group, along with children and pregnant women, should be at the front of the line for being vaccinated, since they are at most risk for developing serious complications from the virus, the CDC has said.

Researchers are examining ways to further stretch vaccine supply. Chen is heading an NIH-sponsored trial on a vaccine with an immune booster added to it, known as adjuvant, starting Monday at the university.

Using an adjuvant - a substance with an oil and water base that is added to the vaccine - could mean having four times as much vaccine supply, Chen said. But adjuvants, used with flu vaccines in Europe, are not licensed for flu vaccines here. Federal approval would require an emergency declaration by the Food and Drug Administration.

Still, Chen thinks studying adjuvants now could prove helpful later in the flu season or in future years.

"Depending how bad H1N1 gets, we may want to stretch out our vaccine supply even further," he said. "This study still addresses a critical issue that is important for public health planning as we get into the flu season."

In addition, no one knows if the vaccine will have adverse effects on people in the long term. So far, the trials done at academic centers nationwide have not shown any immediate problems, other than minor swelling at the site of the shot and arm soreness, Fauci said.

Federal officials said they have stepped up monitoring for possible adverse reactions down the road, specifically, a rare neurological disorder called Guillain-Barre syndrome. After a 1976 outbreak of a different swine flu, the government launched a vaccination effort but some reports found the vaccine increased the risk of Guillain-Barre, which can be fatal.

"It's on people's minds," said Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases. "It's a very rare condition, but it's something we want to be ready for. We might see more Guillain-Barre this fall, because we'll expect to see more flu this fall. We want to know if the vaccine has any kind of link to that. We don't expect that. But we want to be on the lookout."

Novel flu activity is declining in the Southern Hemisphere and in parts of Central America and the Caribbean but increasing in tropical areas of Asia and the Americas and in some parts of the United States and Eastern Europe, the World Health Organization reported today. Oseltamivir-resistant strains have been identified in 21 patients, 12 linked to postexposure prophylaxis and 4 linked to treatment. At least 3,205 deaths have been reported. The WHO also issued school closure guidance today. [WHO pandemic H1N1 update 65]

British officials recently said one of the companies it ordered pandemic H1N1 vaccine from, US-based Baxter, is behind on delivering doses, the Financial Times reported. The government placed about one-third of its order with Baxter for its cell-based product. Baxter had promised 400,000 doses by the end of August, but has delivered only about half that amount. Britain ordered the rest of its vaccine supply from GlaxoSmithKline, which is reportedly on schedule. [Sep 9 Financial Times story]

An official from MedImmune, which is making an inhaled vaccine against pandemic H1N1 influenza, said the company would begin shipping orders to the US government by the end of September, Reuters reported yesterday. The company official, Raburn Mallory, said MedImmune said there are no "red flags" in the safety data submitted to the Food and Drug Administration and that 5 million doses will likely be delivered by the end of the month, about 2 weeks ahead of other pandemic vaccine makers. [Sep 10 Reuters story]

A state-run paper in Egypt carried an announcement from the country's prime minister today that the start of school and universities will be delayed to slow the spread of the pandemic H1N1 virus, the Canadian Press (CP) reported. The school year will begin Oct 3, a week later than planned, to allow those returning from Mecca Ramadan pilgrimages to show illness signs. [Sep 11 CP story]

A new Associated Press-Gallup poll shows seniors are the group most interested in getting the pandemic H1N1 vaccine, and more people in the 18- to 29-year-old age- group are now saying they'll get the shot, the AP reported today. Younger people are bearing the greatest pandemic flu burden, so they are at the front of the line to receive the vaccine. During a normal flu season, seniors are at the front of the line for vaccine because they are among the hardest hit groups. [Sep 11 AP story]

British scientists writing in Emerging Infectious Diseases call for a systematic effort to extend the shelf life of oseltamivir (Tamiflu), as it is one of just two drugs active against the H1N1 virus and is scarce globally. Oseltamivir's chemical profile suggests it should be feasible to extend its shelf life to more than 20 years, the writers say. In May, they note, European authorities said new batches of the drug would have a shelf life of 7 years instead of the previous 5 years. [EID article posted Sep 10]

A New England Journal of Medicine study of children and adults published yesterday showed that receiving recent seasonal flu vaccines produced little or no immune response to this year's novel H1N1 in any age-group. However, 34% of adults older than 60 had cross-reactive antibodies to novel H1N1. Also, vaccination with the 1976 swine flu vaccine substantially boosted cross-reactive antibodies to novel H1N1 in adults. [NEJM study posted Sep 10]

We are encouraged by reports that are now emerging from various clinical trials of 2009 H1N1 influenza vaccines, conducted by various vaccine manufacturers. We expect additional companies to announce their preliminary trial results shortly. The early data from these trials indicate that 2009 H1N1 influenza vaccines are well tolerated and induce a strong immune response in most healthy adults when administered in a single unadjuvanted 15-microgram dose. We congratulate the companies on these trials, which are an important part of the ongoing worldwide effort to develop vaccines to protect the public from 2009 H1N1 influenza.

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, also is conducting clinical trials of 2009 H1N1 influenza vaccines, produced by Sanofi Pasteur and CSL Limited. The NIAID trials are testing two different dosages (15 micrograms versus 30 micrograms) and evaluating the immune response to one and two doses of these vaccines. More than 2,800 people are participating in ongoing NIAID trials of these vaccines.

We are pleased to note that preliminary analyses of early data from the NIAID trials align with the recently announced findings and those to be announced imminently by other companies in that both vaccines studied induced what is likely to be a protective immune response in most adults following a single dose in the same amount (15 micrograms) used in seasonal flu vaccines. Specifically, in blood samples obtained 8 to 10 days after vaccination

Among healthy adults who received a single 15-microgram dose of the Sanofi Pasteur vaccine, a robust immune response was measured in 96 percent of adults aged 18 to 64 and in 56 percent of adults aged 65 and older.Similarly, among healthy adults who received a single 15-microgram dose of the CSL Limited vaccine, a robust immune response was measured in 80 percent of adults aged 18 to 64 and in 60 percent of adults aged 65 and older.Additional data from the NIAID trials are forthcoming. However, on the basis of these strong early data, our results are consonant with other reports that a single 15-microgram dose of unadjuvanted 2009 H1N1 influenza vaccine is well tolerated and induces a robust immune response in healthy adults between the ages of 18 and 64. For adults aged 65 and older, the immune response to 2009 H1N1 influenza vaccine is somewhat less robust, as is the case with seasonal influenza vaccines.

We note that the slight discrepancies seen in our trials between the Sanofi Pasteur and CSL Limited vaccines may be due to technical differences in the preliminary measurement of the amounts of antigen in the doses used in the clinical trial lots and the relatively limited numbers of samples studied to date, as well as the fact that our data are drawn from a very early time point after immunization.

NIAID will continue to provide timely updates on these trials as well as those in children and in pregnant women, which began later.We will join colleagues from across HHS for the weekly H1N1 briefing to be held this week at HHS on Friday at 1:00 PM. The briefing will be shown live at flu.gov.

Information from the NIAID studies will help inform the development of recommendations for immunization schedules, including the optimal dosage and number of doses for different age groups.

NIAID is conducting these clinical trials through its longstanding vaccine clinical trials infrastructure: the Vaccine and Treatment Evaluation Units, a network of medical centers that offers rapid response capability to test vaccines for emerging public health concerns. Detailed information is available from the NIAID Web site and from http://ClinicalTrials.gov.

For more information on influenza, visit www.flu.gov for one-stop access to U.S. government information on avian and pandemic influenza. Also, visit NIAID's Flu Portal.

Jerusalem, Sep 10 : Israel's Central Laboratory for Viral Infections has identified a strand of H1N1 that showed signs of resistance to the Tamiflu drug used to treat swine flu, the ministry of health said Thursday.

The strand was isolated from a sample taken from a swine flu patient in a high risk group that completely recovered from the virus.

The ministry said laboratory tests were continuing and the findings were being evaluated. It noted that resilient forms of the virus have already been discovered elsewhere in the world.

SYDNEY, Sept 11 (Reuters) - The first Australian case of swine flu resistant to Roche Holding AG's antiviral drug Tamiflu was confirmed by the Western Australia state government on Friday.

"The 38-year-old Perth man, who has a weakened immune system, initially responded to the drug but developed a resistant strain of the virus when his illness relapsed," the state's Department of Health said in a statement.

There have been 13 cases of Tamiflu-resistant infections around the world, the statement said.

A Roche executive said on Monday that isolated cases of Tamiflu-resistant H1N1 pandemic flu were to be expected, in line with what has been seen in clinical studies. [ID:nL7314194]

"There is no evidence that the virus has spread to other people. None of the patient's family or hospital staff caring for him have contracted the virus, and he has not been in contact with the wider community," said the state's Chief Health Officer Tarun Weeramanthri, adding that the case was a rare and isolated one.

Initial testing of the 2009 pandemic influenza A (H1N1) virus found it susceptible to neuraminidase inhibitors (oseltamivir and zanamivir) and resistant to adamantanes (amantadine and rimantadine) (1). Neuraminidase inhibitors have been used widely for treatment and chemoprophylaxis of 2009 pandemic influenza A (H1N1); however, sporadic cases of oseltamivir-resistant 2009 pandemic influenza A (H1N1) virus infection have been reported worldwide (2), including nine U.S. cases identified as of September 4.* On July 14, CDC was contacted by a physician at a summer camp in North Carolina regarding two cases of influenza-like illness (ILI) in adolescent girls receiving oseltamivir chemoprophylaxis during an ILI outbreak that had begun June 18. The two girls stayed in the same cabin, and both received oseltamivir during a mass chemoprophylaxis program in which approximately 600 campers and staff members received oseltamivir or zanamivir. On July 20 and July 22, the North Carolina State Laboratory of Public Health confirmed pandemic H1N1 virus infection in respiratory specimens from both girls. On August 14 and August 19, CDC detected the H275Y mutation (N1 numbering) in neuraminidase from both specimens by pyrosequencing (3,4). The H275Y mutation is associated with resistance to oseltamivir; zanamivir susceptibility is retained. A second mutation (I223V) in neuraminidase also was detected in both specimens. This is the first report of oseltamivir resistance in pandemic H1N1 cases with an epidemiologic link. Health-care providers should be aware that antiviral resistance can develop during chemoprophylaxis or treatment with subtherapeutic dosages and should follow published recommendations for antiviral medications (5).

The summer camp offered two 4-week sessions. The first session was conducted from June 14 to July 10, followed by a weekend break, July 11–12, before the start of the second session on July 13. Approximately 650 campers and 350 staff members participated in the first session, and 350 campers and 300 staff members participated in the second session. An outbreak of ILI began on June 18, soon after the start of the first session; the last case was diagnosed on July 22. All ill persons were grouped in isolation until 7 days after symptom onset and until well. All but one of the 61 ill campers and four ill staff members received treatment with either oseltamivir or zanamivir. Also, beginning on June 18, medical staff members conducted a mass program of antiviral chemoprophylaxis in which prophylactic oseltamivir or zanamivir was administered to all persons who had an ill sibling at the camp and to all persons who lived in a cabin with an ill person. Chemoprophylaxis was administered daily by camp staff members to ensure compliance. Over the two sessions, a total of 418 campers and 189 staff members received 10 days of chemoprophylaxis with either oseltamivir (75 mg or appropriate weight-based dosing, once daily) or zanamivir (two 5 mg inhalations, once daily). The camp medical staff continued the program until July 24.

Case Reports

Patient A.

One of the campers, a previously healthy adolescent girl, received oseltamivir prophylaxis at an appropriate prophylactic dose of 75 mg daily during June 26–July 5, despite having no reported exposure to an ill person. After completing the initial course of oseltamivir on July 5, she was exposed to an ill cabin mate (patient C) and administered a second 10-day course of chemoprophylaxis at the same dosage beginning on July 7. On July 8, she experienced cough and headache without fever, and on July 9 she experienced chills, worsening headache, and loose stools. Despite these symptoms, her oseltamivir dose was not increased to a therapeutic treatment dose. On July 10, the last day of the first camp session, she traveled away from camp with three family members while ill, returning on July 12, afebrile and with a cough, to attend the second session. On July 12, a rapid influenza detection test was positive for influenza A. The family declined treatment with zanamivir because of concern over side effects, and the patient’s oseltamivir dose was doubled to 75 mg, twice daily, an appropriate therapeutic treatment dose. Patient A was isolated with other ill campers and staff members until July 16, and she recovered uneventfully. The camp physician observed that the camper became ill while taking prophylaxis and became concerned that antiviral resistance might have occurred. Therefore, a nasopharyngeal swab specimen was obtained on July 14 and sent to the state laboratory for testing. On July 22, the laboratory confirmed the presence of 2009 pandemic influenza A (H1N1) virus by real-time reverse transcription–polymerase chain reaction (rRT-PCR). On August 19, CDC testing of the same clinical specimen detected the H275Y (3,4) and I223V mutations (6). Because viral isolation was unsuccessful, a neuraminidase inhibition assay was not performed. No illness was reported among her family members.

Patient B.

A second previously healthy adolescent girl, who resided in the same cabin as patient A, began oseltamivir chemoprophylaxis at a dose of 75 mg daily on July 7 after exposure to patient C. On July 10, patient B left camp for a home visit during the break between camp sessions. The next day, while at home, she experienced onset of fever (101.9ºF [38.8ºC]), sore throat, and cough. She continued to engage in normal activities while ill, including visiting a shopping mall and movie theater. She returned to camp for the second session on July 12 with fever, headache, cough, malaise, and myalgias. On July 12, a rapid influenza detection test was positive for influenza A. Oseltamivir was discontinued, and zanamivir treatment (two 5 mg inhalations, twice daily) was begun. A nasopharyngeal swab specimen was obtained July 14 and sent to the state laboratory for testing. On July 20, the presence of 2009 pandemic influenza A (H1N1) virus was confirmed by rRT-PCR. On August 14, CDC testing of viral RNA detected H275Y and I223V mutations (3,4,6). Viral isolation was unsuccessful, and a neuraminidase inhibition assay was not performed. Patient B was isolated at the camp during July 12–18. Her fever resolved by July 14, and by July 17 she was asymptomatic. No illnesses were identified among close contacts potentially exposed during her weekend home visit.

Further Transmission Investigation

After identification of the oseltamivir-resistant pandemic H1N1 virus, the state health department and local health departments interviewed the families of the two campers and reviewed camp medical records to determine whether the campers might have transmitted virus to others. Retrospective review of camp records revealed that, during June 26–July 22, six other campers were diagnosed with illness while on oseltamivir chemoprophylaxis (75 mg once daily for 10 days). A single specimen from one of these six campers (not patient C) was obtained July 14 and sent to the state laboratory for testing by rRT-PCR, but no influenza virus was isolated. No evidence of pandemic H1N1 virus infection outside the camp linked to either patient A or patient B was found. CDC tested by pyrosequencing 59 specimens of pandemic H1N1 virus, collected during June 29–August 14 as part of routine surveillance conducted by sentinel sites throughout North Carolina. None of the 59 specimens had the H275Y or I223V mutations.

This report describes confirmed oseltamivir-resistant 2009 pandemic influenza A (H1N1) virus infection in two previously healthy adolescents who were cabin mates and recipients of oseltamivir in a mass chemoprophylaxis program during an outbreak of ILI at a summer camp. This is the first report of oseltamivir resistance in symptomatic close contacts with confirmed infection. Two possible mechanisms of transmission seem most likely. One possibility is that oseltamivir-resistant virus was transmitted from patient A to patient B. The onset of illness for patient B occurred 4 days after the onset of illness for patient A, consistent with reported intervals for secondary transmission among household members with seasonal influenza (7). Alternatively, both patient A and patient B might have acquired oseltamivir-resistant virus infection from exposure to another ill person (e.g., an unknown camper or staff member, or patient C), or each might have developed oseltamivir resistance independently. Whether the H275Y and I223V mutations occurred independently, or whether virus with one or both of these mutations circulated more widely in the camp could not be determined.

Although six other persons had illness while receiving oseltamivir chemoprophylaxis, aside from the specimens collected from patients A and B, only one specimen was obtained from any other ill person, and the pandemic H1N1 virus was not detected in that specimen. Neither mutation was found in 59 surveillance specimens from sentinel sites in the state, suggesting that the mutations were not widespread in North Carolina. The H275Y mutation has been characterized previously among seasonal influenza A (H1N1) viruses and is associated with resistance to oseltamivir (3). The I223V mutation has not been reported previously in 2009 pandemic influenza A (H1N1); because the neuraminidase inhibition assay could not be performed, the mutation’s functional significance is unknown.

These cases highlight a potentially adverse outcome from oseltamivir chemoprophylaxis. In two randomized clinical trials (with 962 and 812 participants, respectively), the efficacy of oseltamivir chemoprophylaxis for preventing clinical seasonal influenza among persons within households ranged from 68% (for laboratory-confirmed infection that included serologic outcomes of infection) to 89% (for laboratory-confirmed clinical influenza) (8,9). No evidence of oseltamivir-resistant virus was reported in these studies. However, the World Health Organization has reported multiple instances of oseltamivir-resistant 2009 pandemic influenza A (H1N1) viruses being isolated from persons who developed pandemic H1N1 infection while receiving oseltamivir chemoprophylaxis (2). Resistance to oseltamivir also might develop during subtherapeutic dosing. In this report, patient A was symptomatic while on a chemoprophylaxis dose of oseltamivir for 4 days. One possibility is that she developed resistance while on a subtherapeutic dosage of 75 mg once a day for chemoprophylaxis, rather than the appropriate treatment dose of 75 mg twice a day.

CDC recommendations regarding use of antivirals during the H1N1 pandemic were updated on September 8. Use of antiviral medications for postexposure chemoprophylaxis should be reserved for persons at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza. An emphasis on early treatment once a patient has developed symptoms, rather than chemoprophylaxis, should reduce opportunities for development of oseltamivir resistance (5). Chemoprophylaxis should not be used for prevention of illness among healthy persons after exposures in community settings. Persons who are taking antiviral medications for prevention should be instructed to contact a health-care provider if illness develops. Persons under antiviral treatment should be instructed to contact a health-care provider if symptoms worsen. Other preventative measures (e.g., hand hygiene and cough etiquette) can reduce the risk for influenza virus transmission (5).

Chemoprophylaxis failure is known to occur even without antiviral resistance (8,9). Accordingly, not all failures need to be accompanied by testing for resistance; testing should be considered for individual cases in consultation with the state health department. However, if symptoms develop during chemoprophylaxis, providers should consider the possibility of antiviral resistance and consider alternate treatment options. Because the 2009 pandemic influenza A (H1N1) virus is resistant to adamantanes (1), limited treatment options will be available if widespread oseltamivir resistance develops. Zanamivir is not licensed for treatment of children aged <7 years and is contraindicated among persons with underlying airway disease.

Wednesday, September 9, 2009

1start the fall media campaign immediately:Tell the media to run a 1 flu story an hr. Dont tell me you cant and dont control the media.We need them to keep panic down, with honest coverage, no frantic stories, just cover the story.

local stations are to run coverage on intended vaccine locations, school closings, supply preperations needed. Tell the pubic no need to be overconcerned, but aware and prepared anyway, it is a flu and deaths will happen as usual with that.

Remind them that any criminal activities or looting with will be dealt with in the harshest of terms. NEW CRIMINALS FROM HERE ON OUT, WILL BE LAST IN LINE FOR ANY TREATMENT OF ANY KIND. This will give the public a sense of added security.

2 rationing ideas if needed.FACE IT there probly will be shortages of something. food, mask, tamiflu,'if not worthless', fever reducers and other meds.foodbanks and the like will be the first to empty.A new Govt emerency proram will have to be announced/implemented for this pandemic...to be immediatly rescinded at the end of it, by law. ANYTHING LESS WILL BE VIEWED AS UNFAIR AND CAUSE PROBLEMS.

To prevent widepread food problems I suggest a rationing card like wartime. thats rite just like ww2.some of these things can only be told of by the president, to maintain order and show authority, seriousness of the situaton and get things off on the right foot.I have ideas for this if needed.Speakng frankly and openly, he has a large minority population that historically is, uneducated, poor but proud, AND AS OF RIGHT NOW,THE HARDEST HIT FROM THIS DISEASE.Make that a talking Point.This type will propagate the spread the fastest and will be the frst to cause trouble. For a lesser govt authourity to announce these actvities will cause trouble.

He can hand these programs off to other depts later but he has to promote these as his ideas and plans, to keep panic and problems under control from the git go. He really need to be on t.v. soon and often to let people know he is on top of the situation.

3Move forward with tents and outside triage areas, clearly marked for flu concerns and suspects. Even if it is early, get the publc used to the idea where to go.

IF DRIVE THRU SHOTS AMINISTERED.Locate these areas to be used now. Small mobile printer like the kind used by parking cops, to give receipt of shots administerd, also give handouts of instructions; where to call if complications, cough ettiquet and the like, a piece of candy for every child.

There may be 1000's at a time lining up, some sick or worried. All police are to treat the public with compassion and respect, as they are scared. To reduce tension; use mobile message sign boards, with current info, calming messages; identification will not be needed, shot is free, where there are other vaccination points, where pregnant people are to go and the like, plus any weather alerts as needed.

People recieve a slip telling of shot received, what type, when and where and when next shot is required. a peice of candy for every child.Prepare needed supples for this. A reg computer and printer will suffice. All computers can be directly linked to main data base, also stored on a disc.

Who do you think you are to control whether my child goes to school during a phase 6 pandemic, that is effectivly killing the young, handicapped, or pregnant.

We need public discusson on school closings.

THE CDC needs a "main "swine flu spokesman, that the people can start to trust.

JUST WHO IS your spokeman?

The public need to think of this as a war, against disease, and needs to be told to get on a war footing, to prevent spread. ..

We need to see the CDC site updated EVERYDAY and say that it is.

Make a vaccine update page.

Television commercials, shows and promo's

where are they?

Where are the billboards?

I need a sticky at the top of EVERY newspaper, EVERY day, with cdc,flu.go website addresses..

Here is a reccomendation.

You better get on the ball with getting the message out it is gonna be bad for certain sections of scociety.

you better get on the ball on reccomending more than 2 weeks

of supplies for the house.

For all the taxes this country pays, all I get is a blank stare on the subject of h1n1.

THIS is YOUR fault.

MAKE them run PSA's. Your little contet i a bunch of crap. rapping dr is good for minors and minorities, but you have a way larger audience than that.

We need to get Hollywood inolved, just like WW2.

Contact them if you havent. We need to see 2 shows a week.

I see we have Elmo, we need MORE, so I suggest these also..

Sid the science kid

Its a big big world

Little Einsteins

Barney and friends

Dora the exploror.

Whoever does the contacting, get them on it!

I suggest Mrs Obama join www.readymoms.org ..make a commercial.. get in a magazine..go to a school.

Where is Oprah?

When Bird flu was happenng she ran a show, now we are in a pandemic and we get nothing??? She is Obama's friend, whats up?? Tell her get busy.

Science and history channel documetaries on vaccines, H1N1, and vaccine production and scientists.

Speak of absolute food safety and precautions taken,I havent seen much talk of that.

How do I know my food is safe.

Is it a risk at all?

You better tell me something or PORK will definitly be off the menu.

Pass a new law for food preperation worker, must wear a mask.

This include butchers.

Involving hospital preps and public preperations

I want to know if you can add a splitter hose to ventelators and help with capacity. Turn it on high and see.. run a test. Try 3 hoses from 1 machine. The inventor is still alive and making ventilators today, here is more on him

Sep 9, 2009 (CIDRAP News) – As children return to school and promptly become infected with H1N1 influenza, emergency-room (ER) physicians nationwide are becoming increasingly anxious over their ERs' capacity to deal with an influx of flu patients.

Many of the physicians work in emergency departments that experienced a spring onslaught of flu and fever cases when H1N1 first struck. In some cities, those cases were part of an early wave that receded; in others, the count of flu cases climbed and has kept climbing through summer months that usually are flu-free.

In either situation, the physicians say they are concerned that the expected fall increase in H1N1 flu—plus the annual arrival of seasonal flu—will significantly perturb a system that has little capacity to handle excess demand. And if H1N1 flu undergoes enough mutation or reassortment to add significant virulence to its notable contagiousness, they add, chaos could result.

Potential for a perfect storm"From what I have been reading, the flu season in the Southern Hemisphere has been very, very bad—they have been swamped with an increasing number of cases," said Dr. Stuart Bradin, an assistant professor of pediatrics and emergency medicine in theUniversity of Michigan Health System."So I think we are in quite a bit of danger of having a very bad flu season here. Having seasonal flu on top of that, and considering that the pandemic flu strain may become more virulent than its initial presentation, I think is the potential for a perfect storm."

Some physicians have been hearing early rumbles of that storm since H1N1 appeared in late April.

"The months of May, June, and July were 3 of our top 6 months ever, in terms of emergency department volume, going back at least 10 years," said Dr. Brian Zink, chair of emergency medicine at Warren Alpert Medical School at Brown University in Rhode Island.

Dr. David Munter, emergency department director at Sentara Obici Hospital in Suffolk, Va., said: "I have never before, in a 28-year career, seen flu in June, July, and August, but we had it, and it was all in teens and young adults. We had no summer dip [in cases] at all."

He added: "I think when school starts, it will explode."

The physicians say that many of the flu patients they saw and expect to see are not gravely ill. Some, especially in the spring, were worried well seeking tests or reassurance. Most who came for care over the summer had fever and other flu-like symptoms, but did not need to be admitted to the hospital and were discharged to recover at home.

The spring wave of cases "increased our wait times and reduced efficiencies," Zink said. "Individuals who needed to be wearing masks, we had to stop and get masked in triage, so it slowed the triage process down. And we went into rooms masked and using contact precautions, which adds a little bit of time to each encounter. But we see 100,000 patients a year in our main hospital [ER], so if you add even a few minutes to each patient, it slows everything down."

ERs already under stressH1N1 arrives at a time when emergency medicine nationwide is widely considered "at the breaking point"—the title of a 2006 Institute of Medicine report on the precarious state of emergency care. That report estimated that ER visits rose by 26% between 1992 and 2003, from 89.8 million to 114 million in a year, while 425 emergency departments and 703 hospitals closed and the number of hospital beds in use shrank by 198,000.

In April of this year, the American Hospital Association updated that calculation in a report that found 50% of 1,078 hospitals were treating more uninsured patients in their ERs, while approximately 10 hospitals per month were laying off 50 staff or more.

Meanwhile, the President's Council of Advisors on Science and Technology estimated in August that H1N1 flu may infect 30% to 50% of the U.S. population this coming winter, leading to as many as 1.8 million hospital admissions that could include 300,000 patients requiring placement in an intensive care unit (ICU). From 30,000 to 90,000 Americans could die, the report said, up to three times as many as die from flu in a normal year.

H1N1's progress through the Southern Hemisphere flu season appears to prefigure that. Last week, Dr. Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), acknowledged that Southern Hemisphere hospitals "had challenges to keep up with the number of people coming in" even though there was "no increase in the level of severity, no increase in the death rate."

Medicine's concern for H1N1's potential impact on ERs is so acute that the American College of Emergency Physicians, emergency medicine's specialty society, in July issued a "National Strategic Plan for Emergency Department Management and Outbreaks of Novel H1N1 Influenza." The plan, written under contract to the Department of Health and Human Services, walks ER directors through a potential H1N1 scenario, lists vulnerabilities that may prove to be weak points, and compiles 27 essential capabilities that ERs must fulfill to handle significant new demand.

Physicians preparing for the fall say uncertainty is a key element in their anxiety. On one hand, H1N1 flu and seasonal flu could cause mostly minor illnesses—but if those mildly ill patients come to ERs, they will take time to interview, assess, and treat, and take staff attention and bed space that might otherwise be devoted to the seriously ill.

That is likely to increase ERs' "length of stay," one key measure of how smoothly an emergency department is functioning. And while they are there, those patients may pose an infection risk to any other patients around them, who may be chronically ill or suffering from any of the underlying conditions that have been implicated in H1N1 deaths to date.

If on the other hand the two flus begin to cause very serious illnesses, they could significantly increase hospital and especially ICU admissions. Such patients might bypass an emergency department or stop in it only briefly, but they could nevertheless have a profound effect on its operations. That is because "boarding," or holding admitted patients in an ER until a bed opens up elsewhere in the hospital—another key measure of ER quality—is created when ICU and ward beds are full.

In a 2006 analysis, the Center for Biosecurity at the University of Pittsburgh Medical Center estimated that responding to a severe pandemic would require 4.6 times as many ICU beds and twice as many hospital beds as exist in the United States.

Strategies for preventing overloadAround the country, emergency departments and the hospitals that house them are crafting solutions that they hope will head off an ER overload. Many are considering creating satellite triage stations located away from ERs—in hospital parking lots, repurposed clinics, or even drive-throughs—all of which rely on keeping flu patients out of the ER and bringing healthcare personnel out to meet them.

Children's Healthcare of Atlanta, which operates three hospitals, recently placed on its website an interactive decision tool that allows parents to assess the severity of a child's symptoms so that only children who need emergency care will be brought to its ERs.

In Virginia, Munter envisions physically dividing his hospital's waiting room into two zones; one, a flu zone, would feed into a pre-designated isolation area within the ER. And the quality-focused Institute for Healthcare Improvement (IHI) will shortly publish a monograph proposing that flu patients be separated more radically, by being steered into what physicians call a "pathway"—a multi-step protocol triggered by a particular set of signs and symptoms—that would not only put them in certain rooms but process them at different speeds depending on results of tests given in a particular rapid order.

Several emergency physicians said that what they fear most for the fall and winter is not an onslaught of flu, but a slow crawl up the epidemic curve. An onslaught, they argued, would be recognized as a crisis and would trigger a coordinated response in the same way a plane crash does. But a steady increase, though it might eventually reach disastrous proportions, would be perceived at any moment as ER business as usual: vastly overcrowded but not deserving outside response.

"Our fear is that it will hit hard enough to really disrupt emergency department operations, but not hard enough to engage crisis-management protocols," said Dr. Joseph "Jody" Crane, a co-author on the forthcoming IHI paper and business director of the Fredericksburg (Md.) Emergency Medical Alliance."That could wreak havoc on the running of emergency departments."hat-tip Chuck

DETAILS: Join us TOMORROW Wednesday, September 9th, from 1-2 PM (EDT) to learn more about how to prevent or reduce the spread of the flu with experts from the Centers for Disease Control and Prevention (CDC) and the Administration for Children and Families at the U.S. Department of Health and Human Services.

HOW CAN YOU PARTICIPATE? Join the discussion by sending questions or comments to hhsstudio@hhs.gov.WHERE CAN I FIND MORE INFORMATION ABOUT WHAT THOSE WITH HIGH RISK CONDITIONS SHOULD DO ABOUT THE FLU?

Flu.gov is your one-stop website for all the latest information about the flu and the new H1N1 flu virus from the CDC and other top scientists and doctors across the federal government. Use our www.flu.gov marketing tools to spread the word about flu.gov to your friends and families and help them get the facts too.

Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season

September 8, 2009 2:00 PM ETObjective

To provide updated guidance on the use of antiviral agents for treatment and chemoprophylaxis of influenza including 2009 H1N1 influenza infection and seasonal influenza, and assist clinicians in prioritizing use of antiviral medications for treatment or chemoprophylaxis for patients at higher risk for influenza-related complications. Additional revisions to these recommendations should be expected as the epidemiology and clinical presentation of 2009 H1N1 influenza is better understood. This guidance can be adapted according to local epidemiologic data, antiviral susceptibility patterns, and antiviral supply considerations. Clinical judgment is always an important part of treatment decisions.

Summary

* Treatment with oseltamivir or zanamivir is recommended for all persons with suspected or confirmed influenza requiring hospitalization.* Treatment with oseltamivir or zanamivir generally is recommended for persons with suspected or confirmed influenza who are at higher risk for complications (children younger than 5 years old, adults 65 years and older, pregnant women, persons with certain chronic medical or immunosuppressive conditions, and persons younger than 19 years of age who are receiving long-term aspirin therapy.* Persons who are not at higher risk for complications or do not have severe influenza requiring hospitalization generally do not require antiviral medications for treatment or prophylaxis. However, any suspected influenza patient presenting with warning symptoms (e.g., dyspnea) or signs (e.g., tachypnea, unexplained oxygen desaturation) for lower respiratory tract illness should promptly receive empiric antiviral therapy.* Clinical judgment is an important factor in antiviral treatment decisions for all patients presenting for medical care who have illnesses consistent with influenza.* Treatment should be initiated as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit.* Treatment should not wait for laboratory confirmation of influenza because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza. The sensitivity of rapid tests can range from 10 % to 70%. View information on the use of rapid influenza diagnostic tests (RIDTs).* Testing for 2009 H1N1 influenza infection with real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) should be prioritized for persons with suspected or confirmed influenza requiring hospitalization and based on guidelines from local and state health departments.* Groups at higher risk for 2009 H1N1 influenza complications are similar to those at higher risk for seasonal influenza complications. * Actions that should be taken to reduce delays in treatment initiation include:o Informing persons at higher risk for influenza complications of signs and symptoms of influenza and need for early treatment after onset of symptoms of influenza (i.e., fever, respiratory symptoms);o Ensuring rapid access to telephone consultation and clinical evaluation for these patients as well as patients who report severe illness;o Considering empiric treatment of patients at higher risk for influenza complications based on telephone contact if hospitalization is not indicated and if this will substantially reduce delay before treatment is initiated.* In selected circumstances, providers might also choose to provide selected patients at higher risk for influenza-related complications (e.g., patients with neuromuscular disease) with prescriptions that can be filled at the onset of symptoms after telephone consultation with the provider.* Antiviral chemoprophylaxis generally should be reserved for persons at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza.* Based on global experience to date, 2009 H1N1 influenza viruses likely will be the most common influenza viruses among those circulating in the coming season, particularly those causing influenza among younger age groups. Circulation of seasonal influenza viruses during the 2009-10 season is also expected. Influenza seasons are unpredictable, however, and the timing and intensity of seasonal influenza virus activity versus 2009 H1N1 circulation cannot be predicted in advance.* Persons with suspected 2009 H1N1 influenza or seasonal influenza who present with an uncomplicated febrile illness typically do not require treatment. However, some groups appear to be at higher risk for influenza-related complications.* Currently circulating 2009 H1N1 viruses are susceptible to oseltamivir and zanamivir, but resistant to amantadine and rimantadine; however, antiviral treatment regimens might change according to new antiviral resistance or viral surveillance information.* Information on the dose and dosing schedule for oseltamivir and zanamivir is provided in this document. An April 2009 Emergency Use Authorization authorizes the emergency use of oseltamivir in children younger than 1 year old, subject to the terms and conditions of the EUA

WASHINGTON (Reuters) - Patients who have flu-like symptoms and are having trouble breathing should get quick treatment with the antiviral drugs Tamiflu or Relenza, even before getting a flu test, U.S. officials said on Tuesday.

And doctors should consider setting up a system so that patients most likely to become severely ill from flu have a prescription on hand so they can just call up if needed to get the go-ahead to take the drugs if they develop symptoms, the U.S. Centers for Disease Control and Prevention said.

"Treatment should not wait for laboratory confirmation of influenza because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza," the CDC says in updated guidelines, available here

But most people will not need any treatment at all for H1N1 because the majority of those infected so far have recovered on their own, the CDC said.

"They can be cared for with mom's chicken soup at home, lots of fluids and rest," the CDC's Dr. Anne Schuchat told reporters.

The swine flu pandemic is likely to keep the flu season going year-round until at least next spring, Schuchat said. The latest guidance suggests officials are keen to make sure people who need it get very quick treatment, while making sure people who do not need the drugs do not abuse them.

Both GlaxoSmithKline's Relenza and Roche AG's Tamiflu can help save the lives of patients severely ill with any influenza, if given within a day or so of symptoms starting. They can also ease the misery of milder cases and even prevent flu if people take it just after exposure.

But supplies are not infinite and health officials worry that the more people who take them, the quicker the virus will evolve resistance, rendering them useless. Two older flu drugs, amantadine and rimantadine, are already useless against seasonal flu.

The CDC is clear that some people should take the drugs prophylactically -- to prevent infection. That includes some healthcare workers treating patients and people with high-risk conditions such as asthma who know they were in close contact with an infected person.

But the new guidance adds an option to watch and see if the person gets a fever. "Instead of the preventive use of antivirals, clinicians may consider watchful waiting," Schuchat said.

A vaccine against H1N1 swine flu is being tested but will not be available until mid-October. The CDC recommends that about 160 million people line up for the first doses starting then.

People at risk of severe flu complications include pregnant women, asthma and diabetes patients, people with heart disease and other chronic illnesses.

WASHINGTON (Dow Jones)--Antiviral drugs Tamiflu and Relenza promptly be given to hospitalized patients suspected of having the flu rather than waiting for influenza test results, according to updated antiviral treatment guidelines issued Tuesday.

In May, the Centers for Disease Control and Prevention issued guidelines for the use of Tamiflu and Relenza by suggesting the drugs be reserved for patients with more severe illnesses as well as those in high-risk groups for complications such as young children and people with underlying health problems like diabetes and heart disease.

Drugs like Tamiflu, by Roche Holding AG (RHHBY), and GlaxoSmithKline PLC's (GSK) Relenza have been shown to reduce the spread of the flu virus in the body and are most effective if given within 12 to 48 hours of the onset of symptoms.

A top CDC official said Tuesday one of the main goals of the updated treatment guidelines is to "narrow the window" between symptom onset and treatment.

Anne Schuchat, the director of CDC's National Center for Immunization & Respiratory Diseases, said, "We don't want providers to wait for test results to become available" to begin treatment with antiviral drugs.

The guidelines also place less emphasis on using the drugs for preventative treatment - such as giving the drugs to people with underlying illnesses who were exposed to H1N1 influenza from a family member. Schuchat said doctors could consider "watchful waiting" to see if exposed patients develop a fever or other flu-like symptoms before starting antiviral treatment. On Monday Roche said it's seen 13 cases of H1N1 becoming resistant to Tamiflu, and cutting down on preventative treatment could slow the development of resistance.

Schuchat also said the majority of Americans who become ill with the flu don't need to seen by their doctors or be given antiviral treatment. Many doctors are no longer testing for H1N1 influenza and the government is no longer tracking individual cases.

Almost all influenza circulating in the U.S. is the H1N1 strain that was first discovered in April. As of Aug. 30, a total of 9,079 hospitalizations and 593 deaths have been attributed to H1N1.